DEPARTMENT OF HEALTH AND SOCIAL SERVICES

Division of Medicaid and Medical Assistance

Statutory Authority: 31 Delaware Code, Section 512 (31 Del.C. §512)

FINAL

ORDER

School-Based Wellness Center Services

Nature of the Proceedings:

Delaware Health and Social Services (“Department”) / Division of Medicaid and Medical Assistance. The Department’s proceedings to amend the Title XIX Medicaid State Plan to add specific reimbursement methodology language for School-Based Wellness Center Clinic Services were initiated pursuant to 29 Delaware Code Section 10114 and its authority as prescribed by 31 Delaware Code Section 512.

The Department published its notice of proposed regulation changes pursuant to 29 Delaware Code Section 10115 in the March 2008 Delaware Register of Regulations, requiring written materials and suggestions from the public concerning the proposed regulations to be produced by March 31, 2008 at which time the Department would receive information, factual evidence and public comment to the said proposed changes to the regulations.

Summary of Proposed Amendment

The purpose of this proposal is to amend the Title XIX Medicaid State Plan to add specific reimbursement language for School-Based Wellness Center Clinic Services.

Statutory Authority

• 42 CFR 440.205, Public Notice of Changes in Statewide Methods and Standards for Setting Payment Rates;

• 42 CFR §440.90, Clinic Services; and,

• State Medicaid Manual, Section 4320, Clinic Services.

Summary of Proposed Amendment

School-Based Wellness Center Clinic Services provide primary prevention and early intervention services, including physical examinations, treatment of acute medical problems, community referrals, counseling and other supportive services to children in school or educational settings.

The Centers for Medicare and Medicaid Services (CMS) advised the State Agency to revise the Title XIX Medicaid State Plan to add specific reimbursement methodology language for School-Based Wellness Center Services.

School-Based Wellness Center Services, operated by the Division of Public Health in Delaware schools, are reimbursed a single rate once each benefit year for any client served in one of the school-based clinics. The single rate is based on prior year statewide costs of all School-Based Wellness Centers.

No change will be made to the services provided under the school-based wellness services benefit.

The provisions of this amendment are subject to approval by the Centers for Medicare and Medicaid Services (CMS).

This proposed regulation was also published concurrently herein under “Emergency Regulations” to allow for public comment.

Summary of Comments Received with Agency Response and Explanation of Changes

The Governor’s Advisory Council for Exceptional Citizens (GACEC) and the State Council for Persons with Disabilities (SCPD) offered the following observations and recommendations summarized below. DMMA has considered the comment and responds as follows:

The Councils understand the Center for Medicare and Medicaid Services (CMS) is prompting DMMA to adopt a funding standard. The DMMA proposes no change in services and it establishes a single rate for each client served in a Wellness Center which would be based on prior year Center costs. We reviewed the amendment and did not identify any concerns.

Agency Response: Your participation is appreciated. Thank you for your comment.

Further analysis by Division staff resulted in changes to the rule as proposed to insert language related to cost reports and interim rates; and, to address upper payment limits as set forth in 42 CFR §447.321. These additions are indicated by [bracketed bold type].

Findings of Fact:

The Department finds that the proposed changes as set forth in the March 2008 Register of Regulations should be adopted.

THEREFORE, IT IS ORDERED, that the proposed regulation regarding the specific reimbursement methodology language for School-Based Wellness Center Services is adopted and shall be final effective May 10, 2008.

Vincent P. Meconi, Secretary, DHSS, April 14, 2008

DMMA FINAL ORDER REGULATIONS #08-13

REVISIONS:

ATTACHMENT 3.1-A

Page 4

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State/Territory: DELAWARE

AMOUNT, DURATION AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY

9. Clinic Services

Clinic services are limited to the following:

• mMedical or rehabilitation clinics (including Mental Health clinics which require certification by the Division of Substance Abuse and Mental Health (DSAMH) as part of the Single State Agency for Medicaid) and

• State Licensed Free Standing Surgical Centers (FSSCs) which equate to Federally defined Ambulatory sSurgical Centers (ACSs) using related policies for ACSs described in Sections 2265 and 2266 of the Medicare Carriers Manual.

• School-Based Wellness Center Clinic Services that provide primary prevention and early intervention services, including physical examinations, treatment of acute medical problems, community referrals, counseling and other supportive services to children in school or educational settings.

(Break in Continuity of Sections)

ATTACHMENT 4.19-B

Page 2

Medical/Dental free-Standing Clinics are paid either a negotiated flat rate or as physicians are paid (see above). School-Based Wellness Center Services, operated by the Division of Public Health in Delaware schools, are reimbursed a single rate once each benefit year for any client served in one of the school-based clinics. The single rate is based [on prior year statewide costs of all School-Based Wellness Centers. cost reports for the prior year submitted in a format specified by the Medicaid agency. An interim rate is paid until the end of the reporting period when there is a retrospective cost settlement. Actual costs reported on the cost report are divided by actual encounters to determine the actual cost per encounter for the period. Actual costs will be compared to interim payments and settlements will be completed.

Payments for clinic services will not exceed the upper payment limits set forth in 42 CFR §447.321: (1) For services covered by Medicare, payments are not to exceed the Medicare rates or the Medicare aggregate payment amount for those services; and, (2) For services not covered by Medicare, aggregate payments are not to exceed an amount that could reasonably be estimated would have been paid under Medicare payment principles.]

11 DE Reg. 1477 (05/01/08) (Final)